A nurse is collecting data from a 6-month-old infant. Which of the following findings should the nurse expect?
The infant has a pincer grasp.
The infant drops objects with the expectation of someone picking them up.
The infant makes babbling sounds.
The infant crawls on their hands and knees.
The Correct Answer is C
Choice C reason: The infant makes babbling sounds. At 6 months of age, it is typical for infants to engage in babbling sounds. Babbling is a significant milestone in language development during infancy. It involves the repetition of consonant-vowel combinations (e.g., "ba-ba,”. "ma-ma") and is an essential precursor to later language skills, such as forming words and sentences. The nurse should expect the 6-month-old infant to be making these babbling sounds as part of their normal development.
Choice A reason:
The infant has a pincer grasp. A pincer grasp is the ability to pick up small objects using the thumb and index finger. This fine motor skill typically develops around 9 to 12 months of age. At 6 months old, infants have not yet acquired the pincer grasp. Therefore, the nurse should not expect the 6-month-old infant to demonstrate this skill during the assessment.
Choice D reason:
The infant crawls on their hands and knees. Crawling is a gross motor skill that usually emerges between 7 to 10 months of age. While some infants may start crawling earlier or later, it is not a skill that is typically present in a 6-month-old. Therefore, the nurse should not anticipate the 6-month-old infant to be crawling on their hands and knees during the assessment.
Choice B reason:
The infant drops objects with the expectation of someone picking them up. This behavior, known as "object permanence,”. is a cognitive milestone that develops around 8 to 12 months of age. At 6 months old, infants have not yet fully developed this concept. They might drop objects as part of their exploratory behavior, but they do not yet understand the expectation of someone picking them up. Therefore, the nurse should not expect the 6- month-old infant to exhibit this specific behavior during the assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
The nurse should inform the adolescent of their right to refuse treatment because respecting the patient's autonomy and right to make their own decisions about their healthcare is essential. This is especially true for an adolescent who is living on their own, as they have the legal capacity to make their medical decisions independently.
Choice B reason:
This statement is incorrect because, in most jurisdictions, adolescents who live on their own are considered emancipated minors, meaning they have the legal right to make their medical decisions without involving a parent or guardian. Requiring a parent or guardian's consent would not be applicable in this situation.
Choice C reason:
This statement is incorrect and irrelevant to the situation. Marriage status does not determine an individual's ability to make their own health care decisions. Regardless of marital status, an adolescent living on their own has the right to make their medical choices.
Choice D reason:
This is the correct choice. The nurse should emphasize the adolescent's right to refuse treatment if they wish to do so. It is crucial to respect their autonomy and ensure that they are fully informed about the potential consequences of their decision. However, the nurse should also provide relevant information about the treatment's benefits and risks to help the patient make an informed decision.
Correct Answer is B
Explanation
Choice A reason:
The nurse should prioritize Choice B over Choice A as it is essential to first confirm the correct placement of the NG tube before proceeding with any other actions. If the tube is not correctly positioned, administering the enteral feeding can lead to potential complications, such as aspiration, which can be life-threatening. Therefore, it is crucial to ensure the NG tube's proper placement before moving forward with the feeding
Choice B reason:
This option takes precedence as verifying the NG tube's position is a fundamental step in the enteral feeding process. The nurse must use appropriate methods, such as X-ray or pH testing, to confirm that the tube is in the stomach and not in the respiratory tract or elsewhere. This verification ensures the safety and effectiveness of the feeding procedure and prevents potential harm to the child.
Choice C reason:
While checking the gastric residual volume (GRV) is an important step in some cases, it should be done after confirming the NG tube's proper placement (Choice B). GRV provides information about the amount of feeding left in the stomach and helps in assessing tolerance to the feeding. However, if the NG tube is misplaced, determining GRV becomes irrelevant as the feeding would not be going to the intended location.
Choice D reason:
Flushing the child's NG tube with sterile water is an appropriate step during the enteral feeding process but should be done after verifying the tube's position (Choice B). Flushing ensures that the tube is patent and free from any obstructions, allowing the feeding to pass through smoothly. However, again, if the NG tube is incorrectly positioned, flushing it would not address the underlying issue.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today